S: Subjective
Information the patient or patient representative told you.
Initials: JT
Age: 28 years
Gender: Female
Height: 170cm
Weight: 88kg BMI: 30.5
BP: 139/87
HR: 82 RR: 16
Temp: 98.9
SPO2: 99%
Pain (1-10): 3/10
Allergies
Medication: Penicillin—Rash
Food: No known allergy
Environment: Cats—Asthma exacerbations
History of Present Illness (HPI)
CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance
"headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For
example: If the patient presents with cough and sore throat, identify which is the CC and which may be an
associated symptom
Chief Complaint (CC): Headache and neck stiffness
Onset: Ms. Jones reports experiencing headaches and neck stiffness for approximately 5 days. She reports, 1 week
ago, being the restrained, front passenger in her friend’s car when they were rear-ended at low speed.
Location: Head and neck
Duration: Approximately 5 days
Characteristics: Dull ache to the crown and back of head. Stiffness of neck
Aggravating Factors: Physical activity
Relieving Factors: Tylenol
Treatment: NA
Current Medications
, SOAP NOTES TEMPLATE
Medication Dosage Frequency Length of Time Reason for Use
Used
Proventil inhaler Albuterol PRN Long term Asthma
90mcg/spray
Tylenol 500mg PRN Unknown Headaches
Advil 600mg TID PRN Unknown Menstrual cramps
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last
tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more
info may be needed.
She has asthma and diabetes type II and exhibits signs and symptoms of peripheral neuropathy to the bilateral soles
of the feet. She denies any surgical history and reports that her last hospitalization for asthma when she was in high
school. She also reports intermittent headaches and blurry vision whenever she has been studying for long periods of
time. She denies having been to an optometrist since she was a child. She reports being treated by a respiratory
specialist until the provider moved away in the past few years. She reports that she is up to date on all childhood
immunizations. Until seeking primary care at this clinic 11 months ago, she was non-compliant with all health
management regimen for several years.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status,
tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all
the time or working smoke detectors in the house
Ms. Jones is very active in church and with family, goes out occasionally with friends dancing, and enjoys bible
study and volunteering with her church. She previously lived alone but moved back in with her mom and younger
sister to help with finances after the death of her father. She is working on her bachelor’s degree in accounting. She
does not use tobacco products or illicit drugs but reports that she tried both when younger. Ms. Jones drinks diet
coke soda and drinks alcohol socially a couple times per month. She is currently single, not sexually active and not
taking contraceptives but used birth control while sexually active with previous partner. She has never been married
and has never been pregnant. She reports a total of three (guy) partners and denies any history of STI’s.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition,
contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be
included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Ms. Jones denies family history of migraines, seizures, Alzheimer’s, and epilepsy but reports family history of CVA.
Ms. Jones’ mom is fifty years old and has hyperlipidemia and hypertension. Her dad is deceased at fifty-eight years
in age from a motor vehicle accident that occurred last year but had a history of hypertension, hyperlipidemia, and
type II diabetes. Her paternal grandmother has hypertension. Her paternal grandfather (Grandpa Jones) died in his
early sixties from colon cancer and had a history of type II diabetes. Ms. Jones’ maternal grandmother (Nana) died at
age seventy-three from a stroke and had a history of hypertension and hyperlipidemia. Her maternal grandfather
(Poppa) died at age seventy-eight from a heart attack and had a history of hypertension and hyperlipidemia. Ms.
Jones has a younger sister and also has asthma. Her brother has no known medical problems, but Ms. Jones reports
that he is overweight as well as most of her family. Her paternal uncle is an alcoholic.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here: Denies all symptoms for this system
Check the box next to each reported symptom and provide additional details.
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